Michael Noble, MD, gave a check up at Integrity Personal Physicians in Lexington, Ky., on Friday, Aug. 13, 2010. The clinic serves a limited number of patients with a yearly flat fee. Photo by Pablo Alcala | Staff

Michael Noble, MD, gave a check up at Integrity Personal Physicians in Lexington, Ky., on Friday, Aug. 13, 2010. The clinic serves a limited number of patients with a yearly flat fee. Photo by Pablo Alcala | Staff

Concierge model provides high-end doctor's visit

No tedious waiting while flipping through outdated magazines. 24/7 access to your doctor that's just a phone call away. And, yes, even house calls.

More and more "concierge" doctors in Central Kentucky are offering these top-flight services for a price — ranging from $1,500 to $4,200 a person annually on top of insurance premiums.

Doctors leaving a traditional general practice say decreasing payments from insurance and shrinking Medicaid and Medicare reimbursements mean they have to take on more and more patients to stay afloat. That results, the physicians contend, in stressed doctors and a reduced quality of care.

So a small number are opting out of that system in favor of concierge services in which patients pay an upfront fee, and the number of patients served by a practice is capped in the hundreds rather than the 1,500 to 2,000 in a typical practice.

The trend, which has been building across the country for about 15 years, is gaining traction in Central Kentucky, with two practices opening in Lexington and one expected to open soon in Versailles. There also are two in in Louisville and at least 12 in Cincinnati.

Many of those are part of the MDVIP network, which partners with doctors to create individual concierge services based on the MDVIP model. The 10-year-old company has more than 134,000 patients and 419 physicians in 29 states, said president Darin Engelhardt. The annual fee per patient is $1,500 to $1,800. Health care reform, with its focus on choice, is likely to push those numbers higher, he said.

"I'm not saying we are the solution," said Engelhardt, "But we are one solution."

But what, exactly, is the problem?

Dr. Michael Karpf, executive vice president for health affairs for UKHealthCare, said there is real pressure on general practitioners. In fact, Kentucky could use about 600 more general practitioners to serve 900,000 to 1.2 million underserved patients. It makes sense that doctors can feel overwhelmed and patients can feel underserved.

Any doctor who sees fewer patients contributes to that deficit, he said. But Karpf doesn't necessarily see concierge doctors having a long-term effect.

It's simply a matter of supply and demand, Karpf explained. He estimates the cost of a concierge service to be $5,000 to $10,000 a year on top of whatever fee is collected. That includes insurance premiums and out-of-pocket expenses for tests and fees for specialists. If you consider that, he said, there just aren't that many people who can afford that kind of care.

"They can't make it work" on a large scale, he said. "It is a niche product."

For those patients who can pay the price, he said, "it can work out very well."

Concierge services have their roots in the tradition of executive physicals in which high-level employees go to a place like the Mayo Clinic for an extensive, and pricey, annual workup, complete with VIP treatment.

When OneMD opened in Louisville in 2002, it took that level of service and made it year-round. The practice started with two doctors, each seeing 300 patients. They have since added a third doctor. The fee is $4,200 a person, and there are 80 people on a waiting list.

Dr. Mark Wheeler, one of the founders, said the growth of the practice reflects the desire for quality care, no matter the cost. It's about choice.

"Some people like to drive a 1992 Yugo," Wheeler said. "I like the luxury that a Toyota Camry gives."

He tried this non-traditional model, he said, "because I got sick of practicing medicine on roller skates."

When he was seeing 60 to 70 patients a day, Dr. Michael Noble said, he felt less like he was practicing medicine and more like he was working on an assembly line.

There were some 18,000 charts at the Paris practice he shared with four other doctors and a physician's assistant. With shrinking reimbursements from insurers and government programs, the practice needed more patients to make the same money.

"The whole goal," he said, "was to see as many patients as possible."

After just a few years of practicing medicine that way, Noble said he started to ask himself: "Is this something I want to do for the rest of my life?"

Noble, who worked a second job as an emergency room doctor to save money to make the shift, has started his own concierge service, Integrity Personal Physicians, in Lexington. His is not the typical doctor's office. There are cotton towels in the bathroom. There is a big screen TV in the waiting area, although the goal is to make sure no one ever really has to wait. He sees seven or eight patients a day.

Noble views concierge service as a way to return to the kind of practice that once was provided by small-town doctors, including house calls.

That kind of personal attention is why Dan Moses signed up his family for the service and the $5,000 fee.

"Not having to wait" was the main attraction, said Moses, a pharmacist. "That's my favorite thing. You can walk in and see (the doctor) instead of waiting."

Dr. Michael Carr, who has practiced in Lexington as an internist for 22 years, is switching to the MDVIP model for many of the same reasons as Noble.

"The current medical system doesn't allow me to spend the personal time with patients that I had in the past," he said. "I want to develop a partnership with them," he said. He had 1,700 active patients but will take a maximum of 600 in his new practice.

"They want this kind of personal care and they deserve this kind of personal care," he said.

Obviously, not everyone can afford that kind of personal care. Annette Boggs said her in-laws, Ray and Betty Ann Boggs who are in their 80s, had been going to Carr for about five years. They have chronic health conditions and made frequent office visits. But they depend on Medicaid.

The couple learned via a letter that Carr was changing his practice. "You would have thought that someone had died on them," Annette Boggs said. After weeks of searching, they found another doctor. But the whole process left Boggs feeling uneasy, she said.

"It would bother me to think that (a doctor) wasn't in this to help people," she said.

Boggs might feel uncomfortable about the shift, but there's nothing in the Hippocratic Oath that says doctors can't make a living, said Karpf. Because of residency requirements, most doctors don't start their own practices until they are 35. They often come out of school with debt of $100,000 to $150,000, he said.

Karpf suggested that those who opt for the concierge model make sure they pick a doctor who will provide the services promised and who has a network of specialists in place to serve all their needs.

Patients, he said, need to think through their health care decisions and consider the total cost of a service beyond the fee.

"They are going to have to understand what they are doing and what it means," he said.

Dr. Michael Noble did a checkup on Elle Moses, 5, at Integrity Personal Physicians. His concierge service limits its patient load.

Dana Moses spoke with Dr. Michael Noble in the waiting room at his new practice. Noble began the "concierge" practice in Lexington so he could spend more time with his patients, who pay a premium for the personal attention.

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